Talent.com
Transitional Care Specialist (TCS)/Medical Assistant
Transitional Care Specialist (TCS)/Medical AssistantDMC • Bedford, NH
Transitional Care Specialist (TCS)/Medical Assistant

Transitional Care Specialist (TCS)/Medical Assistant

DMC • Bedford, NH
30+ days ago
Job type
  • Full-time
Job description
Are you an experienced Medical Assistant who is ready to join a great team?
DMC Primary Care seeks a Certified Medical Assistant for the full-time role of Transitional Care Specialist (TCS). A TCS is responsible for supporting patients as they transition from inpatient, emergency department, skilled nursing, or acute rehab settings back to the primary care environment. The TCS enhances patient outcomes by coordinating follow-up care, conducting structured post-discharge outreach, ensuring timely communication between care teams, and appropriately addressing clinical or social needs that may impact recovery. This role works closely with providers, nursing staff, care managers, and administrative teams to maintain continuity of care and reduce avoidable readmissions.
Duties Include (but are not limited to):
  • Conduct timely post-discharge outreach (phone calls, portal messages, or other approved outreach methods) to assess patient status, confirm discharge instructions, and identify clinical or social concerns.
  • Review hospital or rehabilitation discharge summaries, identify required follow-up actions, and route information to the appropriate provider.
  • Schedule transitional care management (TCM) visits within required timeframes and support patients in overcoming barriers to attending these appointments.
  • Perform structured clinical assessments during outreach calls within CMA scope, including medication reconciliation, symptom check-ins, and identification of red-flag symptoms requiring escalation.
  • Collaborate with primary care providers to ensure timely evaluation of complex cases and communicate urgent issues promptly.
  • Coordinate with care management, behavioral health, social work, home care, and community resource programs to address identified patient needs.
  • Track pending labs, imaging, referrals, or other follow-up items related to transitional care.
  • Support quality improvement initiatives related to care transitions, readmission reduction, and chronic disease management.
  • Participate in interdisciplinary care meetings and provide updates on transitional care caseloads.

This is a full-time hourly position located in Bedford. The successful candidate will have the following qualifications:
Education and Training: High School Diploma (required)
Experience:
  • 3+ years’ experience working in a medical office or healthcare setting
  • 2+ years working as a medical assistant
License & Certification: Medical Assistant certification (preferred)

Full time positions at DMC offer:
  • Paid time off
  • Competitive pay
  • Comprehensive health, dental, prescription, and vision benefits
  • Company-paid short-term disability, long-term disability and life insurance coverages
  • 401k
DMC Primary Care, a physician-owned, independent practice, has been providing comprehensive care for families since 1964. Our offices are located in Bedford, Concord, Derry, Dover, Goffstown, Londonderry, Raymond, and Windham, New Hampshire.
Create a job alert for this search

Transitional Care Specialist (TCS)/Medical Assistant • Bedford, NH

Similar jobs

BC/BE Pulmonary/Critical Care or Critical Care Physician

Diablo Pulmonary Medical GroupConcord, US
Full-time

Diablo Pulmonary Medical Group (DPMG) is seeking a full-time BC/BE Pulmonary/Critical Care or Critical Care Physician to join our growing, well-respected medical group.The practice covers the medic...Show more

 • Promoted

Lead the Future of Thoracic Surgery at Concord Hospital as the Medical Director – Thoracic Surgery

HealthEcareers - ClientConcord, NH, USA
Full-time

Concord Hospital Cardiovascular Institute | Concord, New Hampshire.Concord Hospital Cardiovascular Institute.Medical Director of Thoracic Surgery.Chief of Cardiothoracic Surgery.This is a rare oppo...Show more

 • Promoted

Licensed Nursing Assistant

VLS Systems, Inc.Tilton, NH, United States
Full-time

PM – 11:30 PM 5 days/week including every other weekend.Duration: 13 weeks with extension.LNAs must be qualified to perform duties that include but are' not limited to: |.Providing patients with ba...Show more

 • Promoted

Transitional Assistant Coordinator

Guardian Angel Senior ServicesLeominster, MA, USA
Full-time
Quick Apply

Are you ready to make a meaningful impact in the world of senior care?.Join Guardian Angel Senior Services as a Full-Time Transitional Assistant Coordinator! You'll be at the forefront of helping s...Show more

Travel MRI Tech - $2950 / Week

LancesoftConcord, NH, US
Full-time

Lancesoft is seeking an experienced MRI Tech for an exciting Travel Allied job in Concord, NH.Shift: 4x10 hr nights Start Date: ASAP Duration: 13 weeks Pay: $2950 / Week.We’re proud to be recognize...Show more

 • Promoted

Healthcare Programs Offered - Entry Level Training Programs

DreamboundBedford, New Hampshire, United States
Full-time

Note : This is an educational program, not a job.Successful completion of the program does not guarantee employment but will equip you with valuable skills for the healthcare job market.Are you pas...Show more

 • Promoted

Medical Director Opportunity | Inpatient Behavioral Health

Jackson Physician SearchDevens, US
Full-time

We are seeking an experienced Medical Director to lead an inpatient behavioral health hospital, providing oversight for all clinical programs and services.This physician leader will be responsible ...Show more

 • Promoted

Medical Director for Anesthesia in Leominster, MA

TeamHealth CorporateLeominster, MA, US
Full-time

Looking to elevate your career? Step into a leadership role as a facility medical director with TeamHealth, where you'll have the opportunity to guide a dedicated team, shape the delivery of high-q...Show more

 • Promoted

Clinical Manager - $10,000 Sign On Bonus

Amedisys Inc.Bedford, NH, United States
Full-time

Overview Full time position $10K Sign On Bonus Make a difference every day as an Amedisys registered nurse clinical manager Join Amedisys-one of the largest and most trusted home health and hospice...Show more

 • Promoted

Travel Nurse - RN - LTC - Long Term Care - $2225 / Week - Hiring Now

LRS Healthcare - NursingFranklin, NH, US
Full-time

LRS Healthcare - Nursing is seeking an experienced Long Term Care Registered Nurse for an exciting Travel Nursing job in Franklin, NH.Shift: Inquire Start Date: ASAP Duration: 14 weeks Pay: $2225 /...Show more

 • Promoted

Mail Carrier - City - No Experience Required

Postal Jobs AssistBedford, New Hampshire, United States
Full-time

USPS is accepting applications for City Carrier Assistants nationwide.This role ensures smooth postal operations by delivering mail efficiently.No prior experience is required, as USPS offers compr...Show more

 • Promoted

Pediatrician for Mercyhealth Hospital and Medical Center,Harvard, IL – $258,000 to $315,0000

MercyhealthHarvard, US
Full-time

Mercyhealth System in Harvard, Illinois, is currently seeking a.Board-Certified/Board-Eligible Pediatrician.Build your individual practice as an employed physician with the support of operational l...Show more

 • Promoted

Pulmonary/Critical Care - Part Time & Full Time Positions Available; Student Loan Repayment up to $250,000 and/or Incentive Pay

US ARMY - 1st Medical Recruiting BattalionNone, NH, US
Full-time +1

When you become a pulmonary disease phyiscian and an officer on the U.Army healthcare team, you will have the opportunity to immerse yourself into a special culture and environment in which your di...Show more

 • Promoted

Occupational Therapy Assistant (COTA)

Genesis HealthcareMilford, NH, United States
Full-time +1

Overview **Crestwood Center Has A PRN COTA Opportunity!** At Powerback, we're on a mission to improve lives.As the leader in physical, occupational, speech, and respiratory therapies, we help older...Show more

 • Promoted

Care Transition Specialist

Guardian Home Care of NHNH, US
Permanent
Quick Apply

The Care Transition Specialist plays a critical role in ensuring seamless initiation of services for newly admitted clients by providing immediate coverage during the transition period prior to ass...Show more

Certified Nursing Assistant (CNA) - Full Green Card Sponsorship

Flint Healthcare, IncBedford, New Hampshire
Full-time

Welcome to the US Visa Sponsorship Program by Flint Healthcare, Inc.Please fill in your details so we can assess your fit and reach out to you for an interview should you qualify.We are seeking a c...Show more

 • Promoted

Donor Center Phlebotomist

American Red CrossAmherst, New Hampshire, United States
Full-time

Please use Google Chrome or Mozilla Firefox when accessing Candidate Home.By joining the American Red Cross you will touch millions of lives every year and experience the greatness of the human spi...Show more

 • Promoted

Home Care Aide - Weekly Pay

Home InsteadGreenville, NH, United States
Full-time +1

Experienced Home Caregiver – $19–$24/hr | Local Clients | Weekly Pay.Put your caregiving experience to work close to home.Northern Massachusetts and Southern New Hampshire.Acton, Lowell, Nashua, an...Show more